Ruminations by a non-academic general surgeon from the heart of the rust belt.

Friday, September 18, 2009

Calling Audibles

Peyton Manning's modus operandi is to approach the line, stand there behind his center gazing over the defensive alignment, and then to start barking out commands in cryptic NFL-code. It seems to go on forever. Just run the play, you think. It's annoying as hell. Sometimes it seems as if he's just doing it for show, to draw attention to himself. What he's doing is he's changing the play at the line, he's calling an audible based on the defense's personnel and formation. A lot of times the Colts don't even huddle. Manning just lines the squad up and he calls a play based on what he sees.

In general surgery, we usually just "run the play". Patient has an inguinal hernia, we book the case, and go through the rote maneuvers, almost mindlessly, to repair it. Repetition is good. Muscle memory becomes ingrained. Laparoscopic cholecystectomy becomes an orchestral procession of unspoken movements and techniques. But the wonderful thing about general surgery is that every once in a while you have to improvise; you have to veer off the reservation a bit and change the play at the line of scrimmage.

I had a lady recently who presented with what seemed to be a classic case of gallstone disease. She had developed acute RUQ abdominal pain several hours after eating some chicken wings. The pain radiated to her back and was accompanied by nausea and copius emesis. Her physical exam also supported cholecystitis as the etiology---localized RUQ tenderness, positive Murphy's sign. An ultrasound done in the ER showed multiple stones in the gallbladder, but no typical finding of acute inflammation (wall thickening, pericholecystic fluid). Her blood work showed normal liver function tests and an elevated WBC to 15k. Because she had an acute abdomen, I booked her for a laparoscopic exploration, with intention of doing a lap chole.

We placed our ports, insufflated the abdomen, and started to look around. Her gallbladder was quickly visualized. It had that pearly white appearance that we often see with chronic cholecystitis, but it certainly didn't look acutely inflamed. That bothered me. She was exquisitely tender and had that leukocytosis. Things weren't adding up. So I hesitated. I took a look around. That's the beauty of laparoscopy; the whole peritoneal cavity is your oyster.

Sure enough, I noticed some edema and distortion of the hepatic flexure area of the right colon. The inflammation seemed to extend inferiorly toward the cecum. So I reconnoitered, put in a different port and started to examine the ileal-cecal region a little more closely. I ended up mobilizing much of the right colon from its lateral peritoneal attachments, rolling it over to expose the retroperitoneum. And there was the pathology--- a perforated, retrocecal, gangrenous appendix. The tip of this thing had extended up toward the inferior edge of the right liver. Hence the unusual presentation. But I found the sucker. And the gallbladder lived another day.

I suppose everything would have been easier if the ER had just done the usual, automatic thing and ordered a CT scan on the patient. But then it wouldn't have been nearly as fun. We surgeons like to call our own intra-operative audibles every once in a while too.....

11 comments:

"the usual mindless thing and ordered a CT scan." Wow - do you think we order CTs on everyone that comes in with belly pain? Talk about bringing an ER to a standstill! Don't generalize about ER docs, and I won't generalize about surgeonjerks.

Russ-You're right; a bit of a low blow. I substituted in another word. But you have to admit, the trend in many ER's is to order way too many CT scans. It isn't necessarily mindlessness, but defensive medicine and how busy an ER is when a patient presents with "abdominal pain" certainly plays a role...

Just out of curiosity, why did you not take the gallbladder out as well while you were in there? It sounds pretty clearly like the gallbladder needs to come out (sooner or later) and by doing both at once, you could have saved her another operation.

Or is it more the surgical prudence thing -- do just what you need to and don't ask for more trouble?

Shadow-I guess it would have been reasonable to do so but I think it's always best to "do what you came for"---in this case find out what was causing her sepsis/peritoneal irritation. Let's say she gets a bile leak afterwards. Or an abscess in Morrison's pouch. And then someone asks me under oath someday....but doctor why were you taking out your patient's gallbaldder? You clearly dictate that the patient had appendicitis.... I guess not taking it out is the gen surg form of defensive medicine.

Allen- That's the irony of this case. A CT would have been helpful in planning the operation. Nevertheless, I still think we order too many ER scans. The multitude of gallbladders I have taken out on patients who had Ct scans and HIDA scans done in cases of clear cut cholecystitis on US attests to that....from my anecdotal perspective..

On the other hand, I think we have all ordered belly CTs when we weren't sure of the presenting pathology ("just to be sure") and found something totally unexpected. I used to never do non-contrasted CT scans for painless hematuria, preferring to leave that up to the following MD - until I found about three renal masses in a month! (The patients almost never follow up as recommended) It's a catch-22.

I will admit that we (ER docs) tend to order a lot of CT scans, but we're in a fishbowl - if we miss something (or in most cases, the patient doesn't get timely followup), we get nastygrams from administration. As an example, I took care of an elderly gentleman last week. I had taken care of this fellow about 18 months ago in the ER for a palpitations work up. His wife made a comment that "I almost killed him last time." When I enquired further, she said that when she took him to his regular doctor A MONTH LATER that he had a "gangrenous gallbladder and had to have emergency surgery". Now, how do I, as a lowly ER doc, make the diagnosis of gangrenous cholecystitis on a patient with a chief complaint of palpitations, who has a totally normal CMP, LFTs, and CBC? Makes no sense to me! Maybe I should just do man-scans on everybody and damn the radiation!

I have, on occasion, diagnosed appendicitis and consulted the surgeon without obtaining a CT. Some guys will come in and eval, and some will order a CT - I think it depends on the time of night that I'm calling! Don't get me wrong - I have great respect for general surgeons, and I couldn't do my job without them. But, the animosity that exists between some specialists and the ER is a perpetual thorn in my side that I have to deal with.

yes general surgeons are guilty of over ordering too. I often see ct reqs for classic appy symptoms on an 18 year old... the er doc comes in having woken up an unhappy general surgeon at 3am saying "ok we know it's going to be appendicitis but he won't come in until we get the ct".

yes the er overutilizes radiology, but ct is quick, fast, and accurate -- and that's what the customers in the er want.

the radiation risks are significant and ultimately are going to come back to bite us but for now, the cat scan is the new physical exam.

good points radinc. Gen surgeons definitely are guilty. It used to be a badge of honor to do an appy based on clinical suspicion. Now most GS get the scan, especially after hours. Even on the 21 yo male with a WBC 12 and focal peritoneal findings...

nice link shadowfax -- I'm going to have to add that blog to my bloglines.

I have seen all of those things in the past year (not all in 21 year olds though) so I have to say you are right that they do occur... and not rarely... and they all give rlq pain, anorexia, and a white count.

by the way, that link at the end of that article is what NOT to do with an indeterminate appy on a young female. that's where you get on the phone with the ER and TALK with the docs. I rarely scan a young woman twice and four times I think is a tragedy.

the problem is, if the CT is borderline for appy, often so is the clinical presentation. but in those cases you guys in the ER just have to have some real good followup or bite the bullet with a 24 hour admit.

CT scans are tests and sometimes you get an indeterminate result (I try and limit this as much as possible)

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